Anaphylaxis: past, present and future

Impact of ovalbumin allergy on oral and gut microbiome dynamics in 6-week-old BALB/c mice

Background

The gut microbiota is known to have a significant impact on the development of food allergy, and several recent studies have suggested that both oral microbiota, which first come into contact with allergenic foods, may have a profound influence on the development of food allergy.

Methods

In this study, we have established an ovalbumin-sensitive mice model by utilizing ovalbumin as a sensitizing agent. Subsequently, we performed a comprehensive analysis of the gut and oral microbiota in ovalbumin-sensitive mice and the control mice using full-length 16S rRNA sequencing analysis.

Results

Interestingly, both the gut and oral microbiota of ovalbumin-sensitized mice exhibited significant dysbiosis. The relative abundance of s__Lactobacillus_intestinalis in the gut microbiota of ovalbumin-sensitive mice exhibited a significant decrease, whereas the abundance of s__Agrobacterium_radiobacter and s__Acinetobacter_sp__CIP_56_2 displayed a significant increase. Furthermore, the relative abundance of s__unclassified_g__Staphylococcus, s__Streptococcus_hyointestinalis, and s__unclassified_g__Dechloromonas in the oral microbiota of ovalbumin-sensitive mice revealed a significant decrease. In contrast, the abundance of 63 other species, including s__Proteiniclasticum_ruminis, s__Guggenheimella_bovis, and s__Romboutsia_timonensis, demonstrated a significant increase. The random forest classifier achieved the best accuracy in predicting the outcome of food allergy using three gut and three oral biomarkers, with accuracies of 94.12 and 100%, respectively. Based on the predictions of the PICRUSt2 analysis, the only consistent finding observed across multiple samples from both the groups of mice was a significant up-regulation of the nucleotide-binding oligomerization domain (NOD)-like receptor signaling pathway in the ovalbumin-sensitized mice.

Conclusion

Our study demonstrates that ovalbumin-sensitized mice experience substantial alterations in both gut and oral microbial composition and structure, and specific strains identified in this study may serve as potential biomarkers for food allergy screening. Moreover, our findings highlight that the oral environment, under the same experimental conditions, exhibited greater precision in detecting a larger number of species. Additionally, it is worth noting that the NOD-like receptor signaling pathway plays a vital role in the pathogenesis of OVA (ovalbumin)-induced allergy. These findings will generate novel concepts and strategies in the realm of food allergy prevention and treatment.

Validity and Reliability of the Korean Versions of the Food Allergy Quality of Life Questionnaire-Child Form and Teenager Form

We aimed to assess the validity and reliability of the Korean versions of the Food Allergy Quality of Life Questionnaire-Child Form (K-FAQLQ-CF) and the Food Allergy Quality of Life Questionnaire-Teenager Form (K-FAQLQ-TF). Patients aged 8-17 years with food allergy (FA) were enrolled and completed the Korean versions of the questionnaires, including the K-FAQLQ-CF, the Food Allergy Independent Measure-Child Form (K-FAIM-CF), and the Pediatric Quality of Life Inventory™ (K-PedsQL™ 4.0) for children and the K-FAQLQ-TF, the Food Allergy Independent Measure-Teenager Form (K-FAIM-TF), and the K-PedsQL™ 4.0 for adolescents. We enrolled 56 children and 23 adolescents in this study. The K-FAQLQ-CF showed a good internal consistency (Cronbach's α coefficient = 0.969) and an excellent test-retest reliability (intraclass correlation coefficient = 0.914, P = 0.011). There was a moderate correlation between the K-FAQLQ-CF and K-FAIM-CF scores (β = 0.736, P < 0.001), indicating construct validity. The K-FAQLQ-CF score was weakly associated with the K-PedsQL™ 4.0 score (β = -0.289, P = 0.031), verifying convergent and discriminant validities. The K-FAQLQ-TF also showed a good internal consistency (Cronbach's α coefficient = 0.966) and test-retest reliability (intraclass correlation coefficient = 0.974, P = 0.005). Construct validity was also established by a moderate correlation with the K-FAIM-TF (β = 0.699, P < 0.001). Our results suggest that the K-FAQLQ-CF and K-FAQLQ-TF are valid and reliable tools to evaluate the quality of life of children and adolescents with FA in Korea.

A systematic review and meta-analysis of proteomic and metabolomic alterations in anaphylaxis reactions

Background

Anaphylaxis manifests as a severe immediate-type hypersensitivity reaction initiated through the immunological activation of target B-cells by allergens, leading to the release of mediators. However, the well-known underlying pathological mechanisms do not fully explain the whole variety of clinical and immunological presentations. We performed a systemic review of proteomic and metabolomic studies and analyzed the extracted data to improve our understanding and identify potential new biomarkers of anaphylaxis.

Methods

Proteomic and metabolomic studies in both human subjects and experimental models were extracted and selected through a systematic search conducted on databases such as PubMed, Scopus, and Web of Science, up to May 2023.

Results

Of 137 retrieved publications, we considered 12 for further analysis, including seven on proteome analysis and five on metabolome analysis. A meta-analysis of the four human studies identified 118 proteins with varying expression levels in at least two studies. Beside established pathways of mast cells and basophil activation, functional analysis of proteomic data revealed a significant enrichment of biological processes related to neutrophil activation and platelet degranulation and metabolic pathways of arachidonic acid and icosatetraenoic acid. The pathway analysis highlighted also the involvement of neutrophil degranulation, and platelet activation. Metabolome analysis across different models showed 13 common metabolites, including arachidonic acid, tryptophan and lysoPC(18:0) lysophosphatidylcholines.

Conclusion

Our review highlights the underestimated role of neutrophils and platelets in the pathological mechanisms of anaphylactic reactions. These findings, derived from a limited number of publications, necessitate confirmation through human studies with larger sample sizes and could contribute to the development of new biomarkers for anaphylaxis.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024506246.

Protective effect of Achyranthes aspera against compound 48/80, histamine and ovalbumin-induced allergic disorders in murine model

BACKGROUND

Achyranthes aspera L. (family Amaranthaceae) is a plant species valued in Ayurveda for the treatment of respiratory ailments. Scientific validation of its antiallergic potential was aimed.

METHODS AND RESULTS

Three extracts of A. aspera [aqueous (AaAq), hydroalcoholic (AaHA), ethanolic (AaEt)] were evaluated for their potency against C48/80-induced anaphylaxis in mice at 200 mg/kg BW oral dose. The effective dose of the most potent extract was determined through its effect on C48/80-induced anaphylaxis, and was further analyzed through its effect on mast cell degranulation, histamine-induced bronchospasm and ovalbumin (OVA)-induced asthma in a murine model. Among the three extracts, AaAq was found to be most potent at 200 mg/kg BW. AaAq 400 (400 mg/kg BW) was found to be the most effective dose in terms of inhibition of mortality and histamine level. AaAq 400 prevented the peritoneal and mesenteric mast cells from undergoing morphological changes due to degranulation induced by C48/80. Further, AaAq 400 delayed pre-convulsive time in histamine-induced bronchospasm. In the OVA-induced asthma model, AaAq 400 inhibited the level of inflammatory cell count in blood, bronchoalveolar lavage fluid and peritoneal fluid of mice. The Th2 cytokines (IL-4, IL-5, IL-13), TGF-β and OVA-specific IgE were also reduced as evaluated by ELISA. Also, significant reduction in IL-5 (an eosinophilia indicator) transcript abundance and lung inflammatory score was observed. AaAq was safe up to 4000 mg/kg BW.

CONCLUSIONS

Thus AaAq 400 possesses significant antiallergic potential and acts via attenuation of C48/80-induced anaphylaxis and inhibition of mast cell degranulation. It reduces pre-convulsive dyspnea in histamine-induced bronchospasm and Th2 cytokines in asthmatic mice.

Ketorolac-induced anaphylaxis following oral administration: a case series

Background

Ketorolac is a commonly used non-steroidal anti-inflammatory drug for reducing pain and inflammation. Anaphylaxis is a medical emergency that occurs after exposure to an allergen, with a varied clinical presentation requiring prompt and appropriate measures to prevent or manage it. Although uncommon, ketorolac can cause anaphylaxis requiring immediate medical care. The authors present two cases of anaphylaxis in females induced after oral intake of ketorolac with successful outcomes.

Case presentations

The cases involve two adult women who experienced an allergic reaction to ketorolac. The first woman, aged 36, and the second woman, aged 26, on her second postpartum day, both developed similar types of symptoms like periorbital swelling, itching, and difficulty breathing after taking oral ketorolac. The second woman had a history of allergic rashes. They received immediate treatment with epinephrine, oxygen therapy, intravenous fluids, and other medications. They showed a rapid improvement and were discharged after observation.

Clinical discussion

Anaphylactic reactions to ketorolac, a commonly used pain management drug, have been reported. Symptoms include swelling, difficulty breathing, and hypotension. Treatment involves medications like epinephrine, hydrocortisone, and pheniramine. A detailed medical history, laboratory investigations, appropriate medication, oxygen therapy, and follow-up care are important in managing anaphylactic reactions, which can be life-threatening.

Conclusion

Although rare, ketorolac can cause anaphylactic reactions in patients with or without a history of drug allergy. Immediate recognition and management are essential, along with a detailed medical history and follow-up care.

Epidemiology of out-of-hospital cardiac arrests caused by anaphylaxis and factors associated with outcomes: an observational study

OBJECTIVES

Describe the epidemiologic features of out-of-hospital cardiac arrest (OHCA) caused by anaphylaxis and identify outcome-associated factors.

DESIGN

Observational study.

SETTING

Data from the Japanese Fire and Disaster Management Agency database.

PARTICIPANTS

A total of 292 patients from 879 057 OHCA events between 2013 and 2019 with OHCA caused by anaphylaxis and for whom prehospital resuscitation was attempted were included in the analysis.

OUTCOME MEASURES

The incidence of anaphylaxis-induced OHCA, neurologically favourable 1-month survival, defined as cerebral performance category 1 or 2, and 1-month survival.

RESULTS

The proportion of OHCAs caused by anaphylaxis was high in non-elderly and male patients from July to September and during business hours. Bystander-witnessed (adjusted OR=4.43; 95% CI 1.84 to 10.7) and emergency medical service-witnessed events (adjusted OR=3.28; 95% CI 1.21 to 8.87) were associated with higher rates of neurologically favourable 1-month survival as well as better 1-month survival. Shockable initial ECG rhythms were recorded in only 19 patients (6.5%), and prehospital defibrillation was attempted in 16 such patients (84.2%). Neither shockable initial rhythms nor prehospital defibrillation was associated with better outcomes. Patients requiring advanced airway management had poor neurological outcomes (adjusted OR=0.17; 95% CI 0.07 to 0.42) and worse 1-month survival (adjusted OR=0.28; 95% CI 0.14 to 0.58).

CONCLUSIONS

Few cases of OHCA were attributable to anaphylaxis. Witnessed OHCAs, particularly those witnessed by bystanders, were associated with better neurological outcomes. Airway complications requiring advanced airway management were likely associated with poor outcomes.

Underuse of Epinephrine for the Treatment of Anaphylaxis in the Prehospital Setting

Background

Anaphylaxis is a life-threatening reaction. Its key management is rapid diagnosis and prompt administration of intramuscular epinephrine. There are many barriers to epinephrine use.

Objective

To assess the performance of dispatchers at suspecting anaphylaxis, proposing epinephrine treatment, helping find an epinephrine autoinjector (EAI) and using it.

Methods

This is a retrospective study. Calls classified as “anaphylaxis” or “allergy” were included, and voice recordings were reviewed. Clinical, environmental, and operational variables were collected. Anaphylaxis was suspected if sudden dyspnoea, abdominal symptoms (vomiting, abdominal pain, or diarrhoea), dizziness, or loss of consciousness were present.

Results

The dispatch handled 120,618 dispatch calls. Dispatchers suspected 611 (0.5%) cases of allergy. Among those, 437 (72%) were deemed consistent with anaphylaxis: 65 patients received epinephrine prior to the dispatcher's advice, and dispatchers proposed the use of an EAI to 141 patients (38%). An EAI was available in 45 situations. The proposition was accepted on 18 cases and performed in 16 cases. The median time from the EAI being in hand and the injection was 50 seconds.

Conclusions

Trained dispatchers are able to suspect anaphylaxis, decide when to treat and provide guidance on using an EAI, although their performance can be improved. There is a need for easier access to EAIs in public places.

Pathophysiological, Cellular, and Molecular Events of the Vascular System in Anaphylaxis

Anaphylaxis is a systemic hypersensitivity reaction that can be life threatening. Mechanistically, it results from the immune activation and release of a variety of mediators that give rise to the signs and symptoms of this pathological event. For years, most of the research in anaphylaxis has focused on the contribution of the immune component. However, approaches that shed light on the participation of other cellular and molecular agents are necessary. Among them, the vascular niche receives the various signals (e.g., histamine) that elicit the range of anaphylactic events. Cardiovascular manifestations such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and cardiac alterations are crucial in the pathophysiology of anaphylaxis and are highly involved to the development of the most severe cases. Specifically, the endothelium, vascular smooth muscle cells, and their molecular signaling outcomes play an essential role downstream of the immune reaction. Therefore, in this review, we synthesized the vascular changes observed during anaphylaxis as well as its cellular and molecular components. As the risk of anaphylaxis exists both in clinical procedures and in routine life, increasing our knowledge of the vascular physiology and their molecular mechanism will enable us to improve the clinical management and how to treat or prevent anaphylaxis.

Key Message

Anaphylaxis, the most severe allergic reaction, involves a variety of immune and non-immune molecular signals that give rise to its pathophysiological manifestations. Importantly, the vascular system is engaged in processes relevant to anaphylactic events such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and decreased cardiac output. The novelty of this review focuses on the fact that new studies will greatly improve the understanding of anaphylaxis when viewed from a vascular molecular angle and specifically from the endothelium. This knowledge will improve therapeutic options to treat or prevent anaphylaxis.

The Food Allergy Parent Mentoring Program: A Pilot Intervention

OBJECTIVE

Parents of young children with newly diagnosed food allergy (FA) are at risk for poor psychosocial outcomes due to FA's life-threatening nature and demanding management routines. Presently, there are no interventions to support FA parents during this adjustment phase. This single-arm pilot study explores the feasibility, acceptability, and preliminary efficacy of a novel intervention using peer mentorship to improve psychosocial functioning in parents of young children with newly diagnosed FA.

METHODS

Parent mentors were trained in mentorship and ethics and then matched with a mentee for a 6-month intervention period. Mentees, parents of children (under age 5 years) diagnosed with FA within 1 year, completed baseline and follow-up questionnaires to assess demographic and medical characteristics, FA knowledge, quality of life, self-efficacy, and social support and a program evaluation. Follow-up focus groups with mentors and individual interviews with mentees were conducted.

RESULTS

Participants were 8 mentors and 10 mentees (Mage = 36.60 years, 80% Caucasian) of children ages 0-3 years (Mage = 16.15 months; 60% male). Mentees reported high acceptability for the intervention in program evaluation and interviews, noting improvements in their social support, FA-related stress, confidence in FA management, and positive changes in FA parenting behaviors.

CONCLUSION

This study supports the use of a peer mentorship program to support parents of children with newly diagnosed FA. Future research is needed to determine how to scale this intervention to meet the needs of a large medical division.

A clinical study to optimise a sand fly biting protocol for use in a controlled human infection model of cutaneous leishmaniasis (the FLYBITE study)

Background: Leishmaniasis is a globally important yet neglected parasitic disease transmitted by phlebotomine sand flies. With new candidate vaccines in or near the clinic, a controlled human challenge model (CHIM) using natural sand fly challenge would provide a method for early evaluation of prophylactic efficacy. Methods : We evaluated the biting frequency and adverse effects resulting from exposure of human volunteers to bites of either Phlebotomus papatasi or P. duboscqi, two natural vectors of Leishmania major. 12 healthy participants were recruited (mean age 40.2 ± 11.8 years) with no history of significant travel to regions where L. major-transmitting sand flies are prevalent. Participants were assigned to either vector by 1:1 allocation and exposed to five female sand flies for 30 minutes in a custom biting chamber. Bite frequency was recorded to confirm a bloodmeal was taken. Participant responses and safety outcomes were monitored using a visual analogue scale (VAS), clinical examination, and blood biochemistry. Focus groups were subsequently conducted to explore participant acceptability. Results: All participants had at least one successful sand fly bite with none reporting any serious adverse events, with median VAS scores of 0-1/10 out to day 21 post-sand fly bite. Corresponding assessment of sand flies confirmed that for each participant at least 1/5 sand flies had successfully taken a bloodmeal (overall mean 3.67±1.03 bites per participant). There was no significant difference between P. papatasi and P. duboscqi in the number of bites resulting from 5 sand flies applied to human participants (3.3±0.81 vs 3.00±1.27 bites per participant; p=0.56) .  In the two focus groups (n=5 per group), themes relating to positive participant-reported experiences of being bitten and the overall study, were identified. Conclusions: These results validate a protocol for achieving successful sand fly bites in humans that is safe, well-tolerated and acceptable for participants. Clinicaltrials.gov registration: NCT03999970 (27/06/2019).

Fruit-Induced Anaphylaxis: Clinical Presentation and Management

BACKGROUND

Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis.

OBJECTIVE

To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use.

METHODS

Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting.

RESULTS

We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting.

CONCLUSIONS

Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.

Assessing daily food allergy self-management among adolescents using a 24-hour recall interview

BACKGROUND

Severe food allergic reactions can be life-threatening or fatal and are experienced by up to 40% of children with food allergies, with adolescents at greatest risk. There are no comprehensive measures to assess food allergy management behaviors that could prevent allergic reactions.

OBJECTIVE

To describe food allergy self-management behaviors as reported by adolescents on a 24-hour recall measure and identify related factors.

METHODS

Adolescents aged 10 to 14 years with immunoglobulin E-mediated food allergy completed the Food Allergy Management 24-Hour Recall as an interview. Participants answered questions on each food they ate on the previous day and food allergy self-management behaviors.

RESULTS

Participants were a diverse sample (28% White) of 101 adolescents (mean age = 11.80 years; 53% male sex). Most meals and snacks (76%) were observed by adults. Epinephrine autoinjectors (EAIs) were reportedly available for almost all meals and snacks (93%). Almost all foods had been eaten before (95%) and were verified as allergen free (92%). Furthermore, 35% of the time, past experience with the food was the only method used to verify safety. Child age, number of food allergies, or time since allergic reaction was not related to self-management behavior. EAI availability and ingredient verification were most common at home and in school; adult observation was least likely in the home.

CONCLUSION

Adolescents reported that EAIs were frequently available, but they relied on past experience with food to determine safety. Appropriate assessment of food safety should be a primary intervention target. The Food Allergy Management 24-Hour Recall may be a useful tool to assess and track food allergy self-management.

Knowledge, Attitude, and Practice regarding Anaphylaxis among Pediatric Health Care Providers in a Teaching Hospital

Anaphylaxis is a severe, life threatening generalized or systemic hypersensitivity reaction which requires prompt, accurate diagnosis, and appropriate management. The objective of the study is to assess the extent of knowledge, management skills, and attitude on anaphylaxis among pediatric health care providers of a tertiary care teaching hospital. This was a cross-sectional study done in the department of pediatrics, which included faculty, residents, interns, and nurses. The knowledge, attitude, and practice were assessed using a standardized questionnaire comprised of 35 questions. The questionnaire was distributed and collected in person to all the participants. Informed consent was obtained from all participants and confidentiality was ensured at all stages. Collected data were analyzed using SPSS version 20. The mean of total knowledge score (TKS) was 7.36 ± 1.42. TKS of faculty was 8.36 ± 1.15, in residents 7.81 ± 1.25, in interns 7.46 ± 1.15, and in nurses 6.69 ± 1.57. Knowledge scores of faculty, residents, and interns were significantly higher than that of nurses while there was no significant difference between faculty, residents, and interns. The majority of participants have positive attitude toward anaphylaxis. Incorrect practice is followed by most of the participants. The extent of knowledge about anaphylaxis among pediatric health care providers is moderate but management skills remains suboptimal. Thus, proper training, through continued medical educations and programs to improve abilities to recognize and manage anaphylaxis are very crucial. Differential approach may be followed to different groups; nurses need extra training for optimal management of anaphylaxis.

World allergy organization anaphylaxis guidance 2020

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions. The occurrence of anaphylaxis has increased in recent years, and subsequently, there is a need to continue disseminating knowledge on the diagnosis and management, so every healthcare professional is prepared to deal with such emergencies. The rationale of this updated position document is the need to keep guidance aligned with the current state of the art of knowledge in anaphylaxis management. The World Allergy Organization (WAO) anaphylaxis guidelines were published in 2011, and the current guidance adopts their major indications, incorporating some novel changes. Intramuscular epinephrine (adrenaline) continues to be the first-line treatment for anaphylaxis. Nevertheless, its use remains suboptimal. After an anaphylaxis occurrence, patients should be referred to a specialist to assess the potential cause and to be educated on prevention of recurrences and self-management. The limited availability of epinephrine auto-injectors remains a major problem in many countries, as well as their affordability for some patients.

Risk of peanut- and tree-nut-induced anaphylaxis during Halloween, Easter and other cultural holidays in Canadian children

BACKGROUND

It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut-induced anaphylaxis during certain cultural holidays in Canadian children.

METHODS

We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression.

RESULTS

Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13-2.43 and IRR 1.71, 95% CI 1.21-2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12-3.11 and IRR 1.57, 95% CI 0.94-2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut-induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children.

INTERPRETATION

We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays.

Anaphylaxis diagnosis and management in the Emergency Department of a tertiary hospital in the Philippines

Background

In the Emergency Department (ED), diagnosis and management of anaphylaxis are challenging with at least 50% of anaphylaxis episodes misdiagnosed when the diagnostic criteria of current guidelines are not used.

Objective

Objective of our study was to assess anaphylaxis diagnosis and management in patients presenting to the ED.

Methods

Retrospective chart review conducted on patients presenting to The Medical City Hospital ED, the Philippines from 2013–2015 was done. Cases were identified based on International Statistical Classification of Diseases, 10th revision coding for either anaphylaxis or other allergic related diagnosis. Cases fitting the definition of anaphylaxis as identified by the National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network (NIAID/FAAN) were included. Data collected included demographics, signs and symptoms, triggers and management.

Results

A total of 105 cases were evaluated. Incidence of anaphylaxis for the 3-year study period was 0.03%. Of the 105 cases, 35 (33%) were diagnosed as “urticaria” or “hypersensitivity reaction” despite fulfilling the NIAID/FAAN anaphylaxis criteria. There was a significant difference in epinephrine administration between those given the diagnosis of anaphylaxis versus misdiagnosed cases (61 [87%] vs. 12 [34%], χ² = 30.77, p < 0.01); and a significant difference in time interval from arrival at the ED to epinephrine administration, with those diagnosed as anaphylaxis (48%) receiving epinephrine within 10 minutes, versus ≥ 60 minutes for most of the misdiagnosed group (χ² = 52.97, p < 0.01).

Conclusion

Despite current guidelines, anaphylaxis is still misdiagnosed in the ED. Having an ED diagnosis of anaphylaxis significantly increases the likelihood of epinephrine administration, and at a shorter time interval.

Anaphylaxis to goat/sheep's milk in a 4-year-old boy tolerant to cow's milk

Immune-mediated reactions to dairy products may vary depending on the mammalian source. We present a case of anaphylaxis to goat/sheep's milk with tolerance to cow's milk. A 4-year-old boy of Eastern European descent presented with gastrointestinal and respiratory symptoms within minutes after eating a goat/sheep's milk-derived food product. The tryptase level measured 1 hour post initial symptoms and 1 month after the allergic reaction were 14.6 µg/L and 5.1 µg/L, respectively (norm: 0.0-13.5 µg/L), confirming the diagnosis of anaphylaxis. A skin prick test performed 1 month after the reaction was highly positive for goat/sheep's milk, but negative for cow's milk. Skin prick tests may establish a life-threatening goat/sheep's milk allergy. Goat/sheep's milk allergy should always be considered in cow's milk-tolerant patients who present with an allergic reaction to dairy products, or when undergoing/have completed of oral immunotherapy for cow's milk allergy.

Emergency Call Characteristics and EMS Dispatcher Protocol Adherence for Possible Anaphylaxis

Objective: Anaphylaxis is a medical emergency requiring prompt recognition and treatment with intramuscular epinephrine to optimize outcomes. To date, there is a paucity of data regarding the demographic characteristics of the subset of patients calling 9-1-1 for allergic reactions and the emergency medical services (EMS) dispatcher's adherence to national protocols for their response to a suspected allergic reaction. Methods: We conducted a retrospective review of dispatch calls to a local municipality that were dispatched with an impression of an "allergic reaction" or "difficulty breathing related to a suspected allergic reaction" from January 2016 to June 2016. Using a modified Delphi approach, the voice recordings of the calls were reviewed for EMS dispatcher adherence to the Medical Priority Dispatch System v12.2 (2012) triage questions and pre-arrival instructions for the Allergies/Envenomations and Breathing Problems protocols. The calls were further reviewed for demographic characteristics, symptomatology, history of allergy, suspected trigger of the current reaction, and use and availability of medications. Calls were also classified as to whether the patient met criteria for anaphylaxis. We calculated frequencies for categorical measures and medians with ranges for continuous measures. Results: A total of 146 calls met inclusion criteria. The median age of patients was 29 years (interquartile range 13, 52). 12.3% (n = 18) of the calls reviewed were consistent with national standards for anaphylaxis. Food was the most commonly reported historical allergy, whereas medication accounted for the most commonly suspected trigger for the current symptoms. The EMS dispatcher asked about alertness, difficulty breathing, difficulty speaking, and color change in 39.7, 80.1, 12.3, and 2.7% of calls, respectively. While 56.2% of dispatchers inquired about a history of severe allergy, only 16.4% inquired about prescribed special injections. Conclusions: The majority of calls were not consistent with anaphylaxis, and EMS dispatchers rarely strictly followed the Medical Priority Dispatch System guidelines aimed at identifying anaphylaxis. Future studies would be beneficial to determine if our findings hold true in other EMS service areas.

Missed Registration of Disease Codes for Pediatric Anaphylaxis at the Emergency Department

Background

It is important to register anaphylaxis codes correctly to study the exact prevalence of anaphylaxis. The purpose of this study was to analyze the clinical characteristics and disease codes of inaccurately registered groups in pediatric anaphylaxis patients.

Methods

This study reviewed the medical records of all pediatric patients who presented to the university hospital emergency department over a 5-year period. Study subjects were divided into 2 groups: the accurate group, including those registered under anaphylaxis codes, and the inaccurate coding group, including those registered under other codes.

Results

From a total of 79,676 pediatric patients, 184 (0.23%) had anaphylaxis. Of these, 23 (12.5%) and 161 (87.5%) patients were classified to the accurate and inaccurate coding groups, respectively. Average age, time from symptom onset to emergency department presentation, past history of allergy, and penicillin and cephalosporin as causes of anaphylaxis differed between the 2 groups. Cardiovascular (39.1% vs. 5.6%, p=0.001) and respiratory symptoms (65.2% vs. 42.2%, p=0.038) manifested more frequently in the accurate group, while gastrointestinal symptoms (68.3% vs. 26.1%, p=0.001) were more frequently observed in the inaccurate coding group. Fluid administration (82.6% vs. 28.0%, p=0.001), steroid use (60.9% vs. 23.0%, p=0.001), and epinephrine use (65.2% vs. 13.0% p=0.001) were more common treatments for anaphylaxis in the emergency department in the accurate group. Anaphylaxis patients with cardiovascular symptoms, steroid use, and epinephrine use were more likely to be accurately registered with anaphylaxis disease codes.

Conclusions

In the case of pediatric anaphylaxis, more patients were registered inaccurately under other allergy-related codes and simple symptom codes, rather than under anaphylaxis codes. Therefore, future research on anaphylaxis should consider inaccurately registered anaphylactic patients, as shown in this study.

Traditional Tibetan medicine Anzhijinhua San attenuates ovalbumin-induced diarrhea by regulating the serotonin signaling system in mice

ETHNOPHARMACOLOGICAL RELEVANCE

Tibetan medicine has been practiced for 3800 years. Anzhijinhua San (AZJHS), which is a traditional Tibetan medicine, has been effective in the treatment of indigestion, anorexia and cold diarrhea. However, the effects of AZJHS on allergic diarrhea have not been reported.

AIM OF THE STUDY

The aim of the present study was to elucidate the effect of AZJHS on experimental ovalbumin-induced diarrhea and elucidate its possible mechanism.

MATERIALS AND METHODS

Female BALB/c mice were sensitized by intraperitoneal injection with 50 μg ovalbumin (OVA) and 1 mg alum in saline twice during a 2-week period. From day 28, mice were orally challenged with OVA (50 mg) every other day for a total of ten times. AZJHS (46.8 and 468.0 mg/kg) was orally administered every other day from day 0-46. Food allergy symptoms were evaluated. OVA- specific IgE, 5-HT and its metabolites in serum were determined. Immunohistochemical and histopathology were performed in gastrointestinal tract tissues. 5-HT-related gene expression was assayed in the colon.

RESULTS

Severe symptoms of allergic diarrhea were observed in the model group (diarrhea, anaphylactic response, and rectal temperature). AZJHS (46.8 and 468.0 mg/kg) significantly reduced mouse diarrhea and significantly prevented the increases in OVA-specific IgE levels (P < 0.05), which challenge with OVA. AZJHS (46.8 and 468.0 mg/kg) significantly prevented the increases in 5-HT-positive cells. The nuclei of EC cells in the AZJHS (46.8 and 468.0 mg/kg) group increased in size and the secretory granules were fewer in number compared with those in the model group. AZJHS (46.8 and 468.0 mg/kg) significantly increased the relative fold changes of 5-HTP and 5-HT compared with the model group. The mRNA expression of the serotonin transporter (Sert) and serotonin receptor 3A (Htr3a) was significantly decreased after the 10th challenge with OVA, and AZJHS (46.8 and 468.0 mg/kg) significantly increased these levels.

CONCLUSIONS

We demonstrated that the administration of AZJHS attenuated OVA-induced diarrhea by regulating the serotonin pathway. These results indicated that AZJHS may be a potential candidate as an anti-allergic diarrhea agent.

Diagnosis and management of drug-induced anaphylaxis in children: An EAACI position paper

Drug hypersensitivity reactions (DHR) constitute a major and common public health problem, particularly in children. One of the most severe manifestations of DHR is anaphylaxis, which might be associated with a life-threatening risk. During those past decades, anaphylaxis has received particularly a lot of attention and international consensus guidelines have been recently published. Whilst drug-induced anaphylaxis is more commonly reported in adulthood, less is known about the role of drugs in pediatric anaphylaxis. Betalactam antibiotics and non-steroidal anti-inflammatory drugs are the most commonly involved drugs, probably related to high prescription rates. Diagnosis relies on the recognition of symptoms pattern and is based on complete allergic workup, particularly including skin tests and/or specific IgE. However, the real diagnostic value of those tests to diagnose immediate reactions in children remains not well defined for a significant number of the drugs. Generally, a drug provocation test is discussed to confirm or exclude an immediate-onset drug-induced hypersensitivity. Although avoidance of the incriminated drug (and related drug) is the rule, rapid desensitization is useful in selected subgroups of patients. There is a need for large, multicentric studies, to evaluate the real diagnostic value of the currently available skin tests. Moreover there is also a need to develop new diagnostic tests in the future to improve the management of these children.

Incidence and Outcomes of Severe Anaphylaxis in Paediatric Patients in Atlantic Canada

Little is known about severe anaphylaxis in the pediatric population. In this retrospective cohort study, we aimed to describe the characteristics of children who required admission from an outpatient setting to one of two Pediatric Intensive Care Units in Atlantic Canada with a primary diagnosis of anaphylaxis. During the 10-year study period, there were 12 admissions (58% females) for a population incidence of 2.4 per 100,000 children. Both patients who died were adolescents with a witnessed anaphylaxis event, immediately recognized as such after exposure to a known allergen, with immediate access to epinephrine that was not administered until after cardiorespiratory arrest occurred. This study highlights the high mortality associated with severe anaphylaxis and the ongoing need for education surrounding the early administration of intramuscular epinephrine.

Anaphylactic Degranulation of Mast Cells: Focus on Compound Exocytosis

Anaphylaxis is a notorious type 2 immune response which may result in a systemic response and lead to death. A precondition for the unfolding of the anaphylactic shock is the secretion of inflammatory mediators from mast cells in response to an allergen, mostly through activation of the cells via the IgE-dependent pathway. While mast cells are specialized secretory cells that can secrete through a variety of exocytic modes, the most predominant mode exerted by the mast cell during anaphylaxis is compound exocytosis-a specialized form of regulated exocytosis where secretory granules fuse to one another. Here, we review the modes of regulated exocytosis in the mast cell and focus on compound exocytosis. We review historical landmarks in the research of compound exocytosis in mast cells and the methods available for investigating compound exocytosis. We also review the molecular mechanisms reported to underlie compound exocytosis in mast cells and expand further with reviewing key findings from other cell types. Finally, we discuss the possible reasons for the mast cell to utilize compound exocytosis during anaphylaxis, the conflicting evidence in different mast cell models, and the open questions in the field which remain to be answered.

Identification of Soluble Mediators in IgG-Mediated Anaphylaxis via Fcγ Receptor: A Meta-Analysis

Background: Anaphylaxis is an acute and life-threatening allergic response. Classically and most commonly, it can be mediated by the crosslinking of allergens to immunoglobulin E (IgE)- high affinity IgE receptor (FcεRI) complex found mostly on mast cells. However, there is another pathway of anaphylaxis that is less well-studied. This pathway known as the alternative pathway is mediated by IgG and its Fc gamma receptor (Fcγ). Though it was not documented in human anaphylaxis, a few studies have found that IgG-mediated anaphylaxis can happen as demonstrated in rodent models of anaphylaxis. In these studies, a variety of soluble mediators were being evaluated and they differ from each study which causes confusion in the suitability, and reliability of choice of soluble mediators to be analyzed for diagnosis or therapeutic purposes. Hence, the objective of this meta-analysis is to identify the potential soluble mediators that are involved in an IgG-mediated anaphylaxis reaction.

Methods: Studies related to IgG-mediated anaphylaxis were sourced from five search engines namely PubMed, Scopus, Ovid, Cochrane Library, and Center for Agricultural Bioscience International (CABI) regardless of publication year. Relevant studies were then reviewed based on specific inclusion factors. The means and standard deviations of each soluble mediator studied were then extracted using ImageJ or Get Data Graph Digitiser software and the data were subjected to meta-analysis.

Results: From our findings, we found that histamine, serotonin, platelet activating factor (PAF), β-hexosaminidase, leukotriene C4 (LTC₄), mucosal mast cell protease-1 (MMCP-1), interleukins (IL)-4,−6, and−13; tumor necrosis factor alpha (TNF-α), and macrophage inflammatory protein-1α (MIP-1α) were often being analyzed. Out of these soluble mediators, histamine, PAF, β-hexosaminidase, IL-6, and−13, MIP-1α and TNF-α were more significant with positive effect size and p < 0.001. As study effect was relatively small, we performed publication bias and found that there was publication bias and this could be due to the small sample size studied.

Conclusion: As such, we proposed that through meta-analysis, the potential soluble mediators involved in rodent IgG-mediated anaphylaxis to be histamine, PAF, β-hexosaminidase, IL-6 and−13 and MIP-1α, and TNF-α but will require further studies with larger sample size.

Anaphylaxis to patent blue dye in a 17-year-old boy

Patent blue V dye (PBV) is frequently used as a perioperative drug for lymphangiography, as well as a food additive. Hypersensitivity to PBV is poorly documented in adults and had not been previously described in children. The diagnosis of PBV allergy depends on corroboration of history consistent with an IgE-mediated reaction and confirmatory skin tests. We present in this paper a paediatric case of PBV anaphylaxis and of biphasic reaction that exemplifies the challenges involved in diagnosing and managing this rare but potentially life-threatening allergic reaction.

Pediatric Anaphylaxis in the Emergency Department: Clinical Presentation, Quality of Care, and Reliability of Consensus Criteria

OBJECTIVES

The objective of this study was to describe the quality of emergency department (ED) care for pediatric patients with anaphylaxis. The secondary objectives were to describe (1) the clinical presentation of pediatric patients with anaphylaxis including the proportion of patients meeting each of the National Institute of Allergy and Infectious Diseases (NIAID) consensus criteria and subcriteria and (2) the Interrater reliability (IRR) for applying the NIAID criteria.

METHODS

We conducted a retrospective cross-sectional chart review of patients seen in a pediatric ED during a 2-year period. All charts were reviewed by a trained chart reviewer with 10% abstracted by a second reviewer. Data were analyzed using descriptive statistics including proportions, medians, and interquartile range. Interrater reliability was calculated using Cohen unweighted κ or percent agreement.

RESULTS

Of the 250 charts reviewed, 84% (211) met the NIAID criteria for anaphylaxis (IRR, 1.0). Only 68% of patients received epinephrine in the ED or within 3 hours of the ED visit. Adherence was poor and IRR was variable, for measures reflecting documentation of discharge instructions and follow-up with a specialist. The IRR of reviewers for determining which patients met the NIAID criteria overall and for each subcriterion was high.

CONCLUSIONS

Our findings highlight a gap between best practice and ED care. In addition, our results suggest that the NIAID criteria can reliably be used to retrospectively identify pediatric patients with anaphylaxis. Accurately identifying cases is a prerequisite for measuring gaps in management and developing interventions to improve care.

Use of epinephrine in emergency department depends on anaphylaxis severity in children

Despite multiple recommendations, intramuscular epinephrine is poorly prescribed in emergency department receiving pediatric anaphylaxis. To evaluate the role of severity symptoms on this use, we included all admissions for a diagnosis linked to possible allergy in the two pediatric emergency departments of our institution between January 2010 and December 2015. Selection and analysis were restricted to children under 18 years fulfilling Sampson's criteria for anaphylaxis. We retrospectively ranked these admissions with the Ring and Messmer anaphylaxis severity score and compared the use of epinephrine according to this classification. Among 422,483 admissions, 204 (0.05%) fulfilled the anaphylaxis criteria (170 (83.3%) grade II anaphylaxis, and 34 (16.7%) grade III; mean age 7.9 years). Previous allergy, anaphylaxis, and asthma were found in respectively 60.8%, 36.8%, and 35.1%. Food allergy was the main suspected causal trigger. Epinephrine was used in 32.7% (n = 65/199), before admission (11.4% (n = 23/201)) or in the emergency department (22.2% (n = 45/202)). Epinephrine was more frequently prescribed in grade III than in grade II anaphylaxis (84.8% vs 22.3%, p < 0.001; OR = 19.05 [7.05-54.10]). Upon discharge, epinephrine auto-injectors prescription and allergy referral were rare (31.7% and 44.2%).Conclusion: Pediatricians intuitively adapt their epinephrine use to the severity of the anaphylaxis and contribute to epinephrine underuse in pediatric anaphylaxis. What is known: • Intramuscular epinephrine is the recommended treatment for pediatric anaphylaxis. However, most of the European and North-American studies show a low prescription rate of epinephrine in both prehospital and pediatric emergency department management. • Reasons for such a low prescription rate are unknown. What is new: • This study confirms that intramuscular epinephrine is poorly prescribed in pediatric anaphylaxis (about one case among 10 before admission and one among 5 in pediatric emergency departments). • Despite recommendations, pediatricians intuitively adapt their prescription to the clinical severity of anaphylaxis, with a fourfold increase prescription in grade III compared to grade II anaphylaxis. This medical behavior ascertainment may be in part explained by the delay between the ED admission/management and the anaphylactic episode onset.

Markers of anaphylaxis - a systematic review

Anaphylaxis is defined as severe, life-threatening, systemic or general, immediate reaction of hypersensitivity, with repeatable symptoms caused by the dose of stimulus which is well tolerated by healthy persons. The proper diagnosis, immediate treatment and differential diagnosis are crucial for saving patient's life. However, anaphylaxis is relatively frequently misdiagnosed or confused with other clinical entities. Thus, there is a continuous need for identifying detectable markers improving the proper diagnosis of anaphylaxis. Here we presented currently known markers of anaphylaxis and discussed in more detail the most clinically valuable ones: tryptase, platelet activacting factor (PAF), PAF-acethylhydrolase, histamine and its metabolites.

Prevalence triggers and clinical severity associated with anaphylaxis at a tertiary care facility in Saudi Arabia: A cross-sectional study

Anaphylaxis is a systemic and hypersensitive allergic reaction caused by various triggers such as environmental, food, drug, and insects. The aim of this study was to identify the prevalence, triggers, and clinical severity of anaphylaxis in 2 emergency departments (EDs) in Saudi Arabia.A cross-sectional study based on a screening of medical records was conducted between January 2015 and August 2017, to identify confirmed cases of anaphylaxis. Patient characteristics were age, sex, previously known allergies, and the triggering allergens. The clinical severity was measured on the basis of the anaphylaxis international assessment tool (mild, moderate, severe). Factors associated with triggers and severities were identified.The period prevalence of anaphylaxis among ED admissions was 0.00026%. Pediatric cases (age 1-16 years) were 98 (60.9%), while adults (age 17-40 years) were 63 (39.1%). Triggers of anaphylaxis were food 63 (39.1%), insects 62 (38.5%), drugs 28 (17.4%), and environmental 8 (5.0%). Mild symptoms were observed in 41 (25%) of the sample, while moderate and severe symptoms were observed in 116 (72%) and 4 (3%) of the cases, respectively. Adults were 1.25 times more likely to endure drug allergy rather than food allergy, than pediatrics with adj.P = .015. ED admissions in summer season were 1.29 less likely to be due to drug allergy rather than insect allergy, compared with admissions in winter season, adj.P = .01. Cases with known allergy were 1.72 times less likely to endure drug allergy rather than food allergy, compared with those with unknown allergy, adj.P = .001. Adults were 4.79 more likely to endure severe symptoms than pediatrics with adj.P = .001.Although the prevalence of anaphylaxis was higher in pediatrics, yet the disease was more severe in adults. Special consideration should be paid to anaphylaxis triggered by insect bites in summer, and food allergy among cases with unknown allergy upon ED admission.

Short- and long-term management of cases of venom-induced anaphylaxis is suboptimal

BACKGROUND

Venom-induced anaphylaxis (VIA) accounts for severe reactions. However, little is known about the short- and long-term management of VIA patients.

OBJECTIVE

To assess the short- and long-term management of VIA.

METHODS

Using a national anaphylaxis registry (C-CARE), we identified VIA cases presenting to emergency departments in Montreal and to emergency medical services (EMSs) in western Quebec over a 4-year period. Data were collected on clinical characteristics, triggers, and management. Consenting patients were contacted annually regarding long-term management. Univariate and multivariate logistic regressions were used to identify factors associated with epinephrine use, allergist assessment, and administration of immunotherapy.

RESULTS

Between June 2013 and May 2017, 115 VIA cases were identified. Epinephrine was administered to 63.5% (95% confidence interval [CI], 53.9%-72.1%) of all VIA cases by a health care professional. Treatment of reactions without epinephrine was more likely in reactions occurring at home and in nonsevere cases (no hypotension, hypoxia, or loss of consciousness). Among 48 patients who responded to a follow-up questionnaire, 95.8% (95% CI, 84.6%-99.3%) were prescribed epinephrine auto-injector, 68.8% (95% CI, 53.6%-80.9%) saw an allergist who confirmed the allergy in 63.6% of cases, and 81.0% of those with positive testing were administered immunotherapy. Among cases with follow-up, seeing an allergist was less likely in patients with known ischemic heart disease.

CONCLUSION

Almost 30% of patients with suspected VIA did not see an allergist, only two thirds of those seeing an allergist had allergy confirmation, and almost one fifth of those with confirmed allergy did not receive immunotherapy. Educational programs are needed to bridge this knowledge-to-action gap.

Epidemiology and outcomes of anaphylaxis-associated out-of-hospital cardiac arrest

Background

Understanding the epidemiological characteristics of anaphylaxis-associated out-of-hospital cardiac arrest (OHCA) is the first step toward developing preventative strategies and optimizing care systems. We aimed to describe and compare epidemiological features and clinical outcomes among patients with anaphylaxis-associated OHCAs according to causative agent groups.

Methods

We identified emergency medical service (EMS)-treated anaphylaxis-associated OHCA patients from a nationwide OHCA registry between 2008 and 2015. We compared epidemiological characteristics and outcomes according to causal agents (a natural agents group and an iatrogenic agents group) and evaluated temporal variability in incidence. Multivariate logistic regression analysis was performed to compare survival to discharge between causative agent groups.

Results

During the study period (8 years), the total number of anaphylaxis-associated OHCAs was 233. A total of 224 eligible cases were included in the analysis. There were 192 patients (85.6%) in the natural agents group and 32 patients (14.3%) in the iatrogenic agents group. There was significant diurnal and seasonal variability in the frequency of anaphylaxis-associated OHCAs (p values<0.01 for both), with the highest incidences occurring during the day (7:01 am to 3 pm; 64.6%) and in summer (June to August, 48.7%). Compared with the natural agents group, the adjusted odds ratio (AOR) for survival to discharge in the iatrogenic agents group was statistically insignificant (AOR 3.61, 95% CI 0.86 to 15.06).

Conclusion

The incidence of anaphylaxis-associated OHCA is considerably low, and significant temporal variability, with a peak during the day and in summer, is evident. Anaphylaxis-associated OHCA is more common by natural agents than by iatrogenic agents, but no difference in the survival-to-discharge rate is evident.

Are Registration of Disease Codes for Adult Anaphylaxis Accurate in the Emergency Department?

Purpose

There has been active research on anaphylaxis, but many study subjects are limited to patients registered with anaphylaxis codes. However, anaphylaxis codes tend to be underused. The aim of this study was to investigate the accuracy of anaphylaxis code registration and the clinical characteristics of accurate and inaccurate anaphylaxis registration in anaphylactic patients.

Methods

This retrospective study evaluated the medical records of adult patients who visited the university hospital emergency department between 2012 and 2016. The study subjects were divided into the groups with accurate and inaccurate anaphylaxis codes registered under anaphylaxis and other allergy-related codes and symptom-related codes, respectively.

Results

Among 211,486 patients, 618 (0.29%) had anaphylaxis. Of these, 161 and 457 were assigned to the accurate and inaccurate coding groups, respectively. The average age, transportation to the emergency department, past anaphylaxis history, cancer history, and the cause of anaphylaxis differed between the 2 groups. Cutaneous symptom manifested more frequently in the inaccurate coding group, while cardiovascular and neurologic symptoms were more frequently observed in the accurate group. Severe symptoms and non-alert consciousness were more common in the accurate group. Oxygen supply, intubation, and epinephrine were more commonly used as treatments for anaphylaxis in the accurate group. Anaphylactic patients with cardiovascular symptoms, severe symptoms, and epinephrine use were more likely to be accurately registered with anaphylaxis disease codes.

Conclusions

In case of anaphylaxis, more patients were registered inaccurately under other allergy-related codes and symptom-related codes rather than accurately under anaphylaxis disease codes. Cardiovascular symptoms, severe symptoms, and epinephrine treatment were factors associated with accurate registration with anaphylaxis disease codes in patients with anaphylaxis.

Diagnosis and treatment of anaphylaxis: there is an urgent needs to implement the use of guidelines

Anaphylaxis is a severe, life-threatening generalized or systemic hypersensitivity reaction that requires rapid and adequate care. This study aimed to obtain an integrated view of the level of physicians' knowledge related with treatment of anaphylaxis in studies published within the last 5 years. Sixteen studies were found and four points were identified as of the great interest to the authors: (1) emergency pharmacological treatment, (2) epinephrine auto-injectors prescription, (3) knowledge of the main signs of anaphylaxis, and (4) admission of the patient to verify biphasic reactions. Concern about the use of intramuscular adrenaline as the first choice in relation with anaphylaxis was evident in most studies, rather than its use in the comparison dial, and especially low in a study that included data from Brazil, in which the frequency of its use was 23.8%. An adrenaline autoinjector is highly recommended among specialists for patients at risk of anaphylaxis, however, its use is still infrequent among non-specialists and in countries that this agent is not available. Intervention studies have shown improved medical knowledge of anaphylaxis following disclosure of the information contained in the international guidelines. The analysis of these studies reinforces the need to disseminate international guidelines for diagnosis and treatment of anaphylaxis, as well as providing an adrenaline autoinjector, to improve management and to prevent a fatal outcome.

Who has anaphylaxis in Brazil? Validation of a questionnaire for population studies

Background

The incidence of anaphylaxis is increasing in several parts of the world; thus, determining the prevalence of the disease in a given region is important to understand the factors involved and to promote measures to avoid this type of allergic reaction. Aiming this objective, we validated an instrument for a population-basedstudy that assesses the prevalence of anaphylaxis in the Brazilian population.

Methods

A questionnaire was generated in two variants - one for subjects seven years old or above (Group A) and another for children who were up to six years, 11 months and 29 days (Group B). The instrument was administered to patients with and without anaphylaxis. By allocating points, a score was calculated to differentiate subjects with and without the disease. After validation, the questionnaire was applied in the city of Botucatu (São Paulo state, Brazil), by randomly selecting houses and inviting residents to answer the questionnaire.

Results

The questionnaire was reliable for identifying subjects with and without anaphylaxis in both groups, with a specificity and sensitivity above 90%. The prevalence of anaphylaxis in the pilot survey was 6.2% in Group A, however the evaluation was compromised in Group B by the low number of children below seven years of age due to random sampling of residences.

Discussion

The prevalence of anaphylaxis in our pilot test (6.2%) was similar to major epidemiological surveys from several parts of the world, showing that anaphylaxis is not a rare disease. The instrument of the present work was suitable for this epidemiological survey and might be a good option for studying anaphylaxis in other populations.

Conclusion

This instrument might be of particular value in places where researchers cannot access medical records to conduct similar epidemiological studies.

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug-induced anaphylaxis in Canada

INTRODUCTION

Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children.

OBJECTIVE

We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada.

METHODS

Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests.

RESULTS

From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases.

CONCLUSIONS

Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required.

Epidemiology of drug-induced anaphylaxis in a tertiary hospital in Korea

BACKGROUND

Epidemiology and risk factors of drug-induced anaphylaxis are difficult to estimate due to lack of confirmative diagnosis and under reporting. Here we report the current state of drug-induced anaphylaxis in Korea based on an in-hospital pharmacovigilance database in a tertiary hospital.

METHODS

This study is a retrospective analysis of drug-induced anaphylaxis, reported to an in-hospital pharmacovigilance center in Seoul National University Hospital from June 2009 to May 2013. Anaphylaxis occurred in patients under 18 years of age or developed by medications administered from outside pharmacies or hospitals were excluded. We assessed causative drug, incidence per use of each drug and risk factors of fatal anaphylactic shock.

RESULTS

A total of 152 in-hospital drug-induced anaphylaxis cases were reported during the study period. The single most frequently reported drug was platinum compound and the incidence of anaphylaxis and anaphylactic shock in platinum compounds users was 2.84 and 1.39 per 1000 patients use. Risk factors of anaphylactic shock among total anaphylaxis cases were identified as older age ≥70 years [Odd's ratio (OR), 5.86; 95% confidence interval (CI), 1.70-20.14]. The use of iodinated contrast media (OR, 6.19; 95% CI, 1.87-20.53) and aminosteroid neuromuscular blocking agent (NMBA) (OR, 12.82; 95% CI, 1.50-109.92) were also a risk factor for the development of anaphylactic shock.

CONCLUSIONS

Platinum compounds are the most commonly reported causative agents of in-hospital drug-induced anaphylaxis. Older age ≥70 years and drugs such as iodinated contrast media and aminosteroid NMBA are related with high risk of anaphylactic shock.

"If we are waiting for the numbers alone, we will miss the point": a qualitative study of the perceived rise of food allergy and associated risk factors in the Greater Accra Region, Ghana

Background

Globally, food allergy [FA] is considered a growing health epidemic. While much of what is known comes from developed countries, there is growing interest in the epidemiology of FA in developing regions such as sub-Saharan Africa. Indeed, researchers are beginning to document the incidence and prevalence of FA and sensitization. The results outlined in this paper stem from an exploratory qualitative study examining the emergence of the health risk of FA in Ghana, a country undergoing epidemiologic changes.

Methods

Between June and August, 2015, we conducted thirty-seven (37) semi-structured in-depth interviews. This comprised seventeen (17) healthcare workers across 12 public and private hospitals and twenty (20) individuals with FA and families with allergic children. All interviews were recorded and transcribed verbatim. Transcripts were analyzed to develop thematic areas that characterize perceptions and experiences around FA.

Results

Three key broad themes arise from this study. First, FA is an emerging health risk, whose incidence is perceived to be increasing. Second, participants expressed mixed perceptions about the public health burden of FA. Third, participants identified individual and societal factors that may be influencing FA risks and susceptibility.

Conclusion

Our research suggests FA is a growing but unrecognized public health concern. There is the need for health policies and researchers to consider the full extent of ongoing epidemiologic changes for the health of populations in developing regions.

In Vitro Research Tools in the Field of Human Immediate Drug Hypersensitivity and Their Present Use in Small Animal Veterinary Medicine

Drug hypersensitivity reactions (DHR) are immune-mediated idiosyncratic adverse drug events. Type I DHR are often referred to as "immediate" and involve B lymphocyte-secreted IgE that bind to the membrane of basophils and mast cells, inducing their degranulation. This review presents various in vitro tests that were developed in the field of human type I HS and implemented as clinical diagnostic tools in human cases of immediate DHR. The respective strengths and weaknesses of each test will be discussed in parallel of validation data such as specificity and sensitivity whenever available. Some of them have also been used as diagnostic tools in veterinary medicine, but not in cases of immediate DHR. Most of these diagnostic tools can be categorized into humoral and cellular tests. The former tests measure serum concentrations of factors, such as histamine, tryptase, and drug-specific IgE. The latter assays quantify markers of drug-induced basophil activation or drug-specific lymphocyte proliferation. Pharmacogenetic markers have also been investigated in immediate DHR, but not as extensively as in non-immediate ones. Throughout, practical aspects and limitations of the tests, as well as sensitivity and specificity parameters, will be presented. In addition, the experience of veterinary medicine with these diagnostic tools will be summarized. However, to date, none of them has ever been reported in a veterinary case of type I DHR.

Clinical Management of Psychosocial Concerns Related to Food Allergy

Current estimates indicate that 4% to 8% of children in the United States are diagnosed with food allergy, and more than 40% of US children with food allergy experience severe allergic reactions. Families trying to avoid foods that may trigger an allergic reaction and ensure adequate treatment of allergic reactions that do occur face numerous challenges. The rise in the number of children diagnosed with food allergies underscores the importance of food allergy-related interventions to address elevated psychosocial concerns, such as parenting stress, anxiety, and worries about bullying. This review provides an overview of common psychosocial concerns among children with food allergy and their families across the developmental spectrum, and offers guidance to medical providers regarding the identification and treatment of food allergy-related psychosocial challenges.

Immunology of infusion reactions in the treatment of patients with acute lymphoblastic leukemia

Infusion reactions are potentially dose-limiting adverse events associated with intravenous administration of several common agents used to treat patients with acute lymphoblastic leukemia. True clinical hypersensitivity reactions are antibody-mediated and can occur only after repeated exposure to an antigen. Conversely, anaphylactoid infusion reactions are nonantibody-mediated and often occur on the initial exposure to a drug. Cytokine-release syndrome comprises a subset of nonantibody-mediated infusion reactions associated with the use of monoclonal antibodies and immune therapies. Clinical symptoms of hypersensitivity reactions and nonantibody-mediated infusion reactions heavily overlap and can be difficult to distinguish in practice. Regardless of the underlying mechanism, any infusion reaction can negatively affect treatment efficacy and patient safety. These events require prompt response, and potentially, modification of subsequent therapy.